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2002 Überlingen mid-air collision
The 2002 Überlingen mid-air collision occurred at 23:35 UTC on 1 July 2002 between Bashkirian Airlines Flight 2937 (a Tupolev Tu-154M passenger jet carrying 57 passengers – mostly children – and twelve crew) and DHL Flight 611 (a Boeing 757-23APF cargo jet manned by two pilots) over the towns of Überlingen and Owingen in southern Germany. All 71 people on board the two aircraft were killed. On 19 May 2004, the German Federal Bureau of Aircraft Accidents Investigation (BFU) published its determination that the accident had been caused by shortcomings in the Swiss air traffic control system supervising the flights at the time of the accident and by ambiguities in the use of TCAS, the on-board aircraft collision avoidance system. On 24 February 2004, Peter Nielsen, the air traffic controller on duty at the time of the accident, was stabbed to death by Vitaly Kaloyev. Kaloyev, an architect, had lost his wife and two children in the accident. Flights involved Bashkirian Airlines Flight 2937 was a chartered flight from Moscow, Russia to Barcelona, Spain, carrying sixty passengers and nine crew. Forty-five of the passengers were Bashkortostan schoolchildren on a school trip organized by the local UNESCO committee to the Costa Daurada area of Spain. Most of the parents of the children were high-ranking officials in Bashkortostan."Children's holiday party on doomed plane." CNN. 4 July 2002. Retrieved on 28 April 2010. The aircraft, a Tupolev Tu-154M registered as RA-85816, was piloted by a Russian crew. The captain Alexander Mihailovich Gross (Александр Михайлович Гросс) and first officer Oleg Pavlovich Grigoriev (Олег Павлович Григорьев) flew the Tupolev. Grigoriev, the chief pilot of Bashkirian Airlines, used the trip to evaluate Gross's performance. Murat Ahatovich Itkulov (Мурат Ахатович Иткулов), normally the first officer, did not officially serve on duty because of this. The crew valued the opinions and guidance of Itkulov, who was slated to be promoted to captain. Sergei Kharlov, a navigator, and a flight engineer joined the three pilots."Deadly Crossroads," Mayday DHL Flight 611, a Boeing 757-23APF cargo aircraft registered as A9C-DHL, had originated in Bahrain and was being flown by two Bahrain-based pilots, British captain Paul Phillips and Canadian first officer Brant Campioni. At the time of the accident, it was en route from Bergamo, Italy to Brussels, Belgium. Accident The two aircraft were flying at flight level 360 (approximately 36,000 feet (11,000 m) above Mean Sea Level) on a collision course. Despite being over Germany, the airspace was controlled from Zürich, Switzerland by the private Swiss airspace control company Skyguide. The only air traffic controller handling the airspace, Peter Nielsen, was working two workstations at the same time. He did not realise the problem in time and thus failed to keep the aircraft at a safe distance from each other. Only less than a minute before the accident did he realize the danger and contacted Flight 2937, instructing the pilot to descend by a thousand feet to avoid collision with crossing traffic (Flight 611). Seconds after the Russian crew initiated the descent, however, their traffic collision avoidance system (TCAS) instructed them to climb, while at about the same time the TCAS on Flight 611 instructed the pilots of that aircraft to descend. Had both aircraft followed those automated instructions, it is likely that the collision would not have occurred. Flight 611's pilots on the Boeing jet initially followed the TCAS instructions and initiated a descent, but could not immediately inform the controller due to the fact that he was dealing with Flight 2937. About eight seconds before the collision, Flight 611's descent rate was about 2,400 feet per minute (12 m/s), not as rapid as the 2,500 to 3,000 ft/min (13 to 15 m/s) range advised by TCAS. The Russian pilot on the Tupolev disregarded the TCAS instruction to climb and instead began to descend, as instructed by the controller, thus both planes were now descending. Unaware of the TCAS-issued alerts, Nielsen repeated his instruction to Flight 2937 to descend, giving the Tupolev crew incorrect information as to the position of the DHL plane. Maintenance work was being carried out on the main radar system, which meant that the controllers were forced to use a slower system. The aircraft collided at almost a right angle at an altitude of 34,890 feet (10,630 m), with the Boeing's vertical stabilizer slicing completely through Flight 2937's fuselage just ahead of the Tupolev's wings. The Tupolev exploded and broke into several pieces, scattering wreckage over a wide area. The nose section of the aircraft fell vertically, while the tail section with the engines continued, stalled, and fell. As the nose section of the Tupolev fell at such speed, the flight deck crew soon lost consciousness. The crippled Boeing, now with 80% of its vertical stabilizer lost, struggled for a further seven kilometres (four miles) before crashing into a wooded area close to the village of Taisersdorf at a 70 degree downward angle. Each engine ended up several hundred metres away from the main wreckage, and the tail section was torn from the fuselage by trees just before impact. All 69 people on the Tupolev, and the two on board the Boeing, died. Other factors in the crash Only one air traffic controller, Peter Nielsen of ACC Zurich, was controlling the airspace through which the aircraft were transitioning. The other controller on duty was resting in another room for the night. This was against the regulations, but had been a common practice for years and was known and tolerated by management. Due to maintenance work, Nielsen had a stand-by controller and system manager on call. Nielsen was either unaware of this or he chose not to use either of the two additional air traffic controllers available to him.page 84, section Air traffic situation 1st paragraph When Nielsen realised that the situation had subtly increased beyond his span of control, it was too late to summon assistance. In the minutes before the accident, Nielsen was occupied with an Airbus on a delayed Aero Lloyd Flight 1135 approaching Friedrichshafen Airport.page 16 Handling two workstations at once, Nielsen struggled with the malfunctioning phone system that he was trying to use to call the Friedrichshafen airport to announce the approaching Aero Lloyd. The main phone lines at Skyguide were down due to maintenance work, and the backup line was defective. This caused Nielsen to spend more time than he anticipated coordinating the Airbus late arrival into Friedrichshafen, and to miss several calls from aircraft. The faulty phone lines also prevented adjacent air traffic controllers at Karlsruhe from phoning in a warning. Due to these distractions he did not spot the danger until about a minute before impact. Had he been aware of the dangerous situation earlier, he could have kept the aircraft at a safe distance from each other. They would have been separated and their collision avoidance systems would not have issued instructions. Additionally, after Nielsen instructed the Russian crew to descend, he returned to the situation with the Airbus bound for Friedrichshafen, and did not hear the DHL aircraft TCAS report of its descent. Another factor was that the ground-based optical collision warning system, which would have alerted the controller to imminent collisions early, had been switched off for maintenance; Nielsen was unaware of this. There still was an aural STCA warning system, which released a warning addressed to workstation RE SUED at 21:35:00 (32 seconds before the collision); this warning was not heard by anyone present at that time, although no error in this system could be found in a subsequent technical audit; whether this audible warning is turned on or not, is not logged technically. Even if Nielsen had heard this warning, he might have misinterpreted it until the next radar update 12 seconds later became visible or until the TCAS descent notice by the DHL crew came in; at that time finding a useful resolution order by the air traffic controller is difficult to impossible.page 89 Deviating statements in the official report All countries involved could add additional "deviating" statements to the official report. The Kingdom of Bahrain, Switzerland and the Russian Federation did submit positions that were published with the official report. The USA did not submit deviating positions. The comments were published as an appendix to the report but were not commented upon by the German federal investigators. The statement by the Kingdom of Bahrain, the home country of the DHL plane, mostly agrees with the findings of the report. It says that the report should have put less emphasis on the actions of individuals and stressed the problems with the organisation and management more. Bahrain's statement also mentions the lack of crew resource management in the Tupolev's cockpit as a factor in the crash. The Russian Federation states that the Russian pilots were unable to obey the TCAS advisory to climb; the advisory was given when they were already at 35500 feet while the controller wrongly stated there was conflicting traffic above them at 36000 feet. Also, the controller gave the wrong position of the DHL plane (2 o'clock instead of the actual 10 o'clock). Russia asserts that the DHL crew had a "real possibility" to avoid a collision since they were able to hear the conversation between the Russian crew and the controller. Switzerland notes that the Tupolev was about 33 metres below the flight level ordered by the Swiss controller, and still descending at 1900 feet per minute. The Swiss say that this was also a cause of the accident. The Swiss position also states that in spite of the false information given (position and phraseology) by the Swiss controller the TCAS advisories would have been useful if obeyed immediately. The change in magnetic bearing of the Russian aircraft by cumulatively 20 degrees (from 254 to 274) during the upcoming conflict is not assessed in the official report. Consequences Nielsen needed medical attention due to traumatic stress caused by the accident. At Skyguide, his former colleagues maintained a vase with a white rose over Nielsen's former workstation. Skyguide, after initially having blamed the Russian pilot for the accident, accepted its share of the responsibility and asked relatives of the victims for forgiveness. On 19 May 2004, the official investigators found that managerial incompetence and systems failures were the main cause for the accident, so that Nielsen was surely not the only one to be blamed for the disaster. As explained above, a series of coincidences of which Kaloyev and Nielsen were unaware precipitated the accident. On 27 July 2006, a court in Konstanz decided that the Federal Republic of Germany should pay compensation to Bashkirian Airlines. The court found that it was illegal for the state to allow a foreign private company to provide air traffic control in German airspace. The government appealed the ruling, and a final decision is still pending as of 2008. In another case before the court in Konstanz, Skyguide's liability insurance is suing Bashkirian Airlines for 2.5 million euro in damages. The case was opened in March 2008; the legal questions are expected to be difficult, as the airline has filed for bankruptcy under Russian law. A criminal investigation of Skyguide began . On 7 August 2006, a Swiss prosecutor filed manslaughter charges against eight employees of Skyguide. The Winterthur prosecutor called for prison terms of 6 to 15 months, alleging "homicide by negligence". The verdict was announced in September 2007. Three of the four managers convicted were given suspended prison terms and the fourth was ordered to pay a fine. Another four employees of the Skyguide firm were cleared of any wrongdoing. TCAS and conflicting orders The accident raised questions on how pilots must react when they receive conflicting orders from the TCAS and from air traffic control (ATC). The TCAS is programmed to assume that both crews will promptly follow the system's instructions. The operations manual clearly states that TCAS should always take precedence over any ATC commands: If an instruction to manoeuvre is received simultaneously from an RA (resolution advisory, the command issued by the TCAS) and from ATC, the advice given by RA should be followed. It is not required to notify the ATC prior to responding to an RA. This manoeuvre does not require any ATC clearance since TCAS takes into account the position of all other aircraft with transponders in the surrounding area. Prior incidents About a year before the Bashkirian-DHL collision there had already been another incident involving confusion conflicting TCAS and ATC commands. During the 2001 Japan Airlines mid-air incident, two Japanese airliners nearly collided with each other in Japanese skies. Both aircraft had received conflicting orders from the TCAS and ATC; one pilot followed the instructions of the TCAS while the other did not. Disaster was only averted because one of the pilots made evasive manoeuvres based on a visual judgement. The aircraft missed each other by less than 100 metres (330 ft), and the abrupt manoeuvre necessary to avert disaster left about 100 occupants hurt on one aircraft, some seriously. As a consequence Japan called for measures to prevent similar incidents. However, the International Civil Aviation Organization (ICAO) did not take action until after the crash over Germany. In addition four near misses in Europe occurred before the German disaster, because one set of pilots obeyed the air traffic controllers while the other obeyed TCAS. The ICAO decided to fulfill Japan's request 18 months after the Japan Airlines incident. Unclear instructions for the Bashkirian crew The Bashkirian pilots were using the Tu-154 Flight Operations Manual, which contained a section that emphasizes the role of the ATC and describes the TCAS as an additional aid:page 53 The same flight manual, on a different page, also contains a passage that strictly forbids manoeuvers contrary to the TCAS under any circumstances. Nevertheless, the official investigation found that the pilots seemed unaware that the TCAS RA should take precedence.page 103 Technical solutions Before this accident a change proposal (CP 112)Change proposal CP112E for the TCAS II system had been issued. This proposal would have created a "reversal" of the original warning - asking the DHL plane to climb and the Tupolev crew to descend. According to an analysis by Eurocontrol this would have avoided the collision if the DHL crew had followed the new instructions and the Tupolev had continued to descend.page 35 Additionally, an automatic downlink for the TCAS - which would have alerted the air traffic controller - had not been deployed worldwide at the time of the accident.page 50 Recommendations after the accident The investigation report contains a number of recommendations concerning TCAS, calling for upgrades and for better training and clearer instructions to the pilots. Notable passengers on Flight 2937 Fourteen-year old Kirill Degtyarev created paintings from age 4 to his death and had held two public exhibitions. After his death, Ufa hosted one exhibition and Überlingen hosted another exhibition. The family of future deputy North Ossetian housing minister Vitaly Kaloyev all died. Kaloyev would later go on to murder Nielsen. Murder of Peter Nielsen Grieved by the loss of his family, Vitaly Kaloyev held Peter Nielsen responsible for their deaths. He stabbed Nielsen to death at his Kloten home, near Zürich, on 24 February 2004."Swiss air crash controller killed." CNN. Wednesday 25 February 2004. Retrieved on 29 January 2010. Police arrested Kaloyev at a local motel not long after the murder, and he was subsequently convicted of the crime in 2005. He was released on 8 November 2007 because his mental condition was not sufficiently considered in the initial sentence. After his release, Kaloyev was infamously dubbed a "hero" in North Ossetia. In January 2008, he was appointed deputy construction minister of North Ossetia. Dramatization The Discovery Channel Canada documentary series ''Mayday featured this accident in the episode titled Deadly Crossroads, which was released in 2004.IMDb The National Geographic Channel documentary series Seconds From Disaster featured this mid-air collision in the episode entitled Collision at 35,000 feet release in 26th September 2011. "Flug in die Nacht - Das Unglück von Überlingen" (2009), ("Flight into the night - the accident at Überlingen") produced by German and Swiss TV stations SWR and SF, is a motion picture based on the crash and the subsequent killing of the air traffic controller. Related Articles * TCAS * Gol Transportes Aéreos Flight 1907 External links * Final Report - German Federal Bureau of Aircraft Accidents Investigation (English) **Appendices 1 and 3 ** Appendix 2 * Final Report - German Federal Bureau of Aircraft Accidents Investigation - The German version is the version of record ** Appenices 1 and 3 ** Appendix 2 * "Information regarding the air accident at Überlingen on 1 July 2002." Skyguide. * District Court of Kostanz Bashkirian Airlines v. Federal Republic of Germany * Photo documentary from Owingen Fire Dept. (German) - Official website from Owingen Fire Dept. with photos from a firefighter's perspective * Identifying the factors that contributed to the Ueberlingen mid-air collision (PDF 322 KB) - University of Illinois * Gallery of crash victim Kyrill Degtyarev's works * 'The Uberlingen mid-air collision: Lessons for the management of control rooms in the process industries', Loss Prevention Bulletin issue 196, 2007, IChemE, UK. On conflicting orders * ACAS II bulletin from Eurocontrol: Follow the RA! (PDF) * ACAS guiding material: CAP 579 (PDF) * Script for Case Study – Mid Air Collision over Ueberlingen Überlingen Mid-Air Collision, 2002 Category:Aviation accidents and incidents caused by air traffic controller error Category:Airliner accidents and incidents caused by pilot error Category:Aviation accidents and incidents in 2002 Category:Aviation accidents and incidents in Germany Category:Mid-air collisions Category:DHL Category:Accidents and incidents involving the Tupolev Tu-154 Category:Accidents and incidents involving the Boeing 757 Category:Airliner accidents and incidents involving mid-air collisions Category:UNESCO Überlingen Mid-Air Collision, 2002 Category:Aviation accidents and incidents caused by air traffic controller error Category:Airliner accidents and incidents caused by pilot error Category:Aviation accidents and incidents in 2002 Category:Aviation accidents and incidents in Germany Category:Mid-air collisions Category:DHL Category:Accidents and incidents involving the Tupolev Tu-154 Category:Accidents and incidents involving the Boeing 757 Category:Airliner accidents and incidents involving mid-air collisions Category:UNESCO Überlingen Mid-Air Collision, 2002 Category:Aviation accidents and incidents caused by air traffic controller error Category:Airliner accidents and incidents caused by pilot error Category:Aviation accidents and incidents in 2002 Category:Aviation accidents and incidents in Germany Category:Mid-air collisions Category:DHL Category:Accidents and incidents involving the Tupolev Tu-154 Category:Accidents and incidents involving the Boeing 757 Category:Airliner accidents and incidents involving mid-air collisions Category:UNESCO Überlingen Mid-Air Collision, 2002 Category:Aviation accidents and incidents caused by air traffic controller error Category:Airliner accidents and incidents caused by pilot error Category:Aviation accidents and incidents in 2002 Category:Aviation accidents and incidents in Germany Category:Mid-air collisions Category:DHL Category:Accidents and incidents involving the Tupolev Tu-154 Category:Accidents and incidents involving the Boeing 757 Category:Airliner accidents and incidents involving mid-air collisions Category:UNESCO